|
AMOXICILLIN 125MG/5ML SUSP PER 5ML DOSE
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 00781604146
|
| Hospital Charge Code |
3300051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$3.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
AMOXICILLIN 250MG/5ML SUSP PER 5ML DOSE
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 00781604146
|
| Hospital Charge Code |
3300053
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.40
|
| Rate for Payer: First Health Workers Compensation |
$2.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5.40
|
| Rate for Payer: GEHA Commercial |
$4.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Multiplan All |
$5.46
|
| Rate for Payer: OMNI Networks Commercial |
$4.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5.58
|
| Rate for Payer: Zelis Auto |
$2.40
|
| Rate for Payer: Zelis Worker's Compensation |
$1.64
|
|
|
AMOXICILLIN 250MG/5ML SUSP PER 5ML DOSE
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 00781604146
|
| Hospital Charge Code |
3300053
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.60
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.40
|
| Rate for Payer: First Health Workers Compensation |
$2.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5.40
|
| Rate for Payer: GEHA Commercial |
$4.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Humana ChoiceCare |
$1.56
|
| Rate for Payer: Multiplan All |
$5.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.60
|
| Rate for Payer: OMNI Networks Commercial |
$4.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5.58
|
| Rate for Payer: Zelis Auto |
$2.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.64
|
|
|
AMOXICILLIN 250MG CAP
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 00781202001
|
| Hospital Charge Code |
3300052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.40
|
| Rate for Payer: First Health Workers Compensation |
$2.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5.40
|
| Rate for Payer: GEHA Commercial |
$4.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Multiplan All |
$5.46
|
| Rate for Payer: OMNI Networks Commercial |
$4.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5.58
|
| Rate for Payer: Zelis Auto |
$2.40
|
| Rate for Payer: Zelis Worker's Compensation |
$1.64
|
|
|
AMOXICILLIN 250MG CAP
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 00781202001
|
| Hospital Charge Code |
3300052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.60
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$5.10
|
| Rate for Payer: First Health Commercial |
$5.40
|
| Rate for Payer: First Health Workers Compensation |
$2.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5.40
|
| Rate for Payer: GEHA Commercial |
$4.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5.40
|
| Rate for Payer: Humana ChoiceCare |
$1.56
|
| Rate for Payer: Multiplan All |
$5.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.60
|
| Rate for Payer: OMNI Networks Commercial |
$4.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5.70
|
| Rate for Payer: Three Rivers Provider Network All |
$4.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5.58
|
| Rate for Payer: Zelis Auto |
$2.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.64
|
|
|
AMOXICILLIN K CLAV 200-28.5MG TAB
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 00781161966
|
| Hospital Charge Code |
3300054
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9.60
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$13.60
|
| Rate for Payer: First Health Commercial |
$14.40
|
| Rate for Payer: First Health Workers Compensation |
$6.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14.40
|
| Rate for Payer: GEHA Commercial |
$12.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14.40
|
| Rate for Payer: Humana ChoiceCare |
$4.16
|
| Rate for Payer: Multiplan All |
$14.56
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.60
|
| Rate for Payer: OMNI Networks Commercial |
$11.20
|
| Rate for Payer: One Health Plan PPO/POS |
$14.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15.20
|
| Rate for Payer: Three Rivers Provider Network All |
$12.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$14.88
|
| Rate for Payer: Zelis Auto |
$6.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.00
|
| Rate for Payer: Zelis Worker's Compensation |
$4.37
|
|
|
AMOXICILLIN K CLAV 200-28.5MG TAB
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 00781161966
|
| Hospital Charge Code |
3300054
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.37 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$13.60
|
| Rate for Payer: First Health Commercial |
$14.40
|
| Rate for Payer: First Health Workers Compensation |
$6.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14.40
|
| Rate for Payer: GEHA Commercial |
$11.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14.40
|
| Rate for Payer: Multiplan All |
$14.56
|
| Rate for Payer: OMNI Networks Commercial |
$11.20
|
| Rate for Payer: One Health Plan PPO/POS |
$14.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15.20
|
| Rate for Payer: Three Rivers Provider Network All |
$12.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$14.88
|
| Rate for Payer: Zelis Auto |
$6.40
|
| Rate for Payer: Zelis Worker's Compensation |
$4.37
|
|
|
AMOXICILLIN K CLAV 250-125MG TAB
|
Facility
|
IP
|
$41.00
|
|
|
Service Code
|
NDC 00781187431
|
| Hospital Charge Code |
3300055
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$38.95 |
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$34.85
|
| Rate for Payer: First Health Commercial |
$36.90
|
| Rate for Payer: First Health Workers Compensation |
$15.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.90
|
| Rate for Payer: GEHA Commercial |
$28.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.90
|
| Rate for Payer: Multiplan All |
$37.31
|
| Rate for Payer: OMNI Networks Commercial |
$28.70
|
| Rate for Payer: One Health Plan PPO/POS |
$36.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.95
|
| Rate for Payer: Three Rivers Provider Network All |
$30.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$38.13
|
| Rate for Payer: Zelis Auto |
$16.40
|
| Rate for Payer: Zelis Worker's Compensation |
$11.19
|
|
|
AMOXICILLIN K CLAV 250-125MG TAB
|
Facility
|
OP
|
$41.00
|
|
|
Service Code
|
NDC 00781187431
|
| Hospital Charge Code |
3300055
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$38.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$34.85
|
| Rate for Payer: First Health Commercial |
$36.90
|
| Rate for Payer: First Health Workers Compensation |
$15.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$36.90
|
| Rate for Payer: GEHA Commercial |
$32.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$36.90
|
| Rate for Payer: Humana ChoiceCare |
$10.66
|
| Rate for Payer: Multiplan All |
$37.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.60
|
| Rate for Payer: OMNI Networks Commercial |
$28.70
|
| Rate for Payer: One Health Plan PPO/POS |
$36.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$38.95
|
| Rate for Payer: Three Rivers Provider Network All |
$30.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$36.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$10.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$38.13
|
| Rate for Payer: Zelis Auto |
$16.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$20.50
|
| Rate for Payer: Zelis Worker's Compensation |
$11.19
|
|
|
AMOXICILLIN K CLAV 500-125MG TAB
|
Facility
|
OP
|
$29.00
|
|
|
Service Code
|
NDC 00093227434
|
| Hospital Charge Code |
3300056
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.25 |
| Max. Negotiated Rate |
$27.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$17.40
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$24.65
|
| Rate for Payer: First Health Commercial |
$26.10
|
| Rate for Payer: First Health Workers Compensation |
$11.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$26.10
|
| Rate for Payer: GEHA Commercial |
$23.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$26.10
|
| Rate for Payer: Humana ChoiceCare |
$7.54
|
| Rate for Payer: Multiplan All |
$26.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$17.40
|
| Rate for Payer: OMNI Networks Commercial |
$20.30
|
| Rate for Payer: One Health Plan PPO/POS |
$26.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$27.55
|
| Rate for Payer: Three Rivers Provider Network All |
$21.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$25.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$26.97
|
| Rate for Payer: Zelis Auto |
$11.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$14.50
|
| Rate for Payer: Zelis Worker's Compensation |
$7.92
|
|
|
AMOXICILLIN K CLAV 500-125MG TAB
|
Facility
|
IP
|
$29.00
|
|
|
Service Code
|
NDC 00093227434
|
| Hospital Charge Code |
3300056
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$27.55 |
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$24.65
|
| Rate for Payer: First Health Commercial |
$26.10
|
| Rate for Payer: First Health Workers Compensation |
$11.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$26.10
|
| Rate for Payer: GEHA Commercial |
$20.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$26.10
|
| Rate for Payer: Multiplan All |
$26.39
|
| Rate for Payer: OMNI Networks Commercial |
$20.30
|
| Rate for Payer: One Health Plan PPO/POS |
$26.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$27.55
|
| Rate for Payer: Three Rivers Provider Network All |
$21.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$26.97
|
| Rate for Payer: Zelis Auto |
$11.60
|
| Rate for Payer: Zelis Worker's Compensation |
$7.92
|
|
|
AMOXICILLIN K CLAV 875-125MG TAB
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 00093227534
|
| Hospital Charge Code |
3300057
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$7.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
AMOXICILLIN K CLAV 875-125MG TAB
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 00093227534
|
| Hospital Charge Code |
3300057
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$8.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Humana ChoiceCare |
$2.86
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.60
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.50
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
AMOXIXILLIN 400MG/5ML SUSP PER 5 ML DOSE
|
Facility
|
IP
|
$22.25
|
|
|
Service Code
|
NDC 65862007101
|
| Hospital Charge Code |
3303199
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.07 |
| Max. Negotiated Rate |
$21.14 |
| Rate for Payer: Cash Price |
$13.35
|
| Rate for Payer: Cigna Commercial |
$18.91
|
| Rate for Payer: First Health Commercial |
$20.02
|
| Rate for Payer: First Health Workers Compensation |
$8.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$20.02
|
| Rate for Payer: GEHA Commercial |
$15.57
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$20.02
|
| Rate for Payer: Multiplan All |
$20.25
|
| Rate for Payer: OMNI Networks Commercial |
$15.57
|
| Rate for Payer: One Health Plan PPO/POS |
$20.02
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$21.14
|
| Rate for Payer: Three Rivers Provider Network All |
$16.69
|
| Rate for Payer: United Payors & United Providers UP&UP |
$20.69
|
| Rate for Payer: Zelis Auto |
$8.90
|
| Rate for Payer: Zelis Worker's Compensation |
$6.07
|
|
|
AMOXIXILLIN 400MG/5ML SUSP PER 5 ML DOSE
|
Facility
|
OP
|
$22.25
|
|
|
Service Code
|
NDC 65862007101
|
| Hospital Charge Code |
3303199
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.56 |
| Max. Negotiated Rate |
$21.14 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$13.35
|
| Rate for Payer: Cash Price |
$13.35
|
| Rate for Payer: Cigna Commercial |
$18.91
|
| Rate for Payer: First Health Commercial |
$20.02
|
| Rate for Payer: First Health Workers Compensation |
$8.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$20.02
|
| Rate for Payer: GEHA Commercial |
$17.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$20.02
|
| Rate for Payer: Humana ChoiceCare |
$5.79
|
| Rate for Payer: Multiplan All |
$20.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$13.35
|
| Rate for Payer: OMNI Networks Commercial |
$15.57
|
| Rate for Payer: One Health Plan PPO/POS |
$20.02
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$21.14
|
| Rate for Payer: Three Rivers Provider Network All |
$16.69
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$19.58
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5.56
|
| Rate for Payer: United Payors & United Providers UP&UP |
$20.69
|
| Rate for Payer: Zelis Auto |
$8.90
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$11.12
|
| Rate for Payer: Zelis Worker's Compensation |
$6.07
|
|
|
AMOX K CLAV 250-62.5MG/5ML SUSP
|
Facility
|
OP
|
$307.00
|
|
|
Service Code
|
NDC 00029609039
|
| Hospital Charge Code |
3300048
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$76.75 |
| Max. Negotiated Rate |
$291.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$184.20
|
| Rate for Payer: Cash Price |
$184.20
|
| Rate for Payer: Cigna Commercial |
$260.95
|
| Rate for Payer: First Health Commercial |
$276.30
|
| Rate for Payer: First Health Workers Compensation |
$118.53
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$276.30
|
| Rate for Payer: GEHA Commercial |
$245.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$276.30
|
| Rate for Payer: Humana ChoiceCare |
$79.82
|
| Rate for Payer: Multiplan All |
$279.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$184.20
|
| Rate for Payer: OMNI Networks Commercial |
$214.90
|
| Rate for Payer: One Health Plan PPO/POS |
$276.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$291.65
|
| Rate for Payer: Three Rivers Provider Network All |
$230.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$270.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$76.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$285.51
|
| Rate for Payer: Zelis Auto |
$122.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$153.50
|
| Rate for Payer: Zelis Worker's Compensation |
$83.81
|
|
|
AMOX K CLAV 250-62.5MG/5ML SUSP
|
Facility
|
IP
|
$307.00
|
|
|
Service Code
|
NDC 00029609039
|
| Hospital Charge Code |
3300048
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$83.81 |
| Max. Negotiated Rate |
$291.65 |
| Rate for Payer: Cash Price |
$184.20
|
| Rate for Payer: Cigna Commercial |
$260.95
|
| Rate for Payer: First Health Commercial |
$276.30
|
| Rate for Payer: First Health Workers Compensation |
$118.53
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$276.30
|
| Rate for Payer: GEHA Commercial |
$214.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$276.30
|
| Rate for Payer: Multiplan All |
$279.37
|
| Rate for Payer: OMNI Networks Commercial |
$214.90
|
| Rate for Payer: One Health Plan PPO/POS |
$276.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$291.65
|
| Rate for Payer: Three Rivers Provider Network All |
$230.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$285.51
|
| Rate for Payer: Zelis Auto |
$122.80
|
| Rate for Payer: Zelis Worker's Compensation |
$83.81
|
|
|
AMOX K CLAV 400-57MG/5ML SUSP
|
Facility
|
IP
|
$332.00
|
|
|
Service Code
|
NDC 00029609239
|
| Hospital Charge Code |
3300049
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.64 |
| Max. Negotiated Rate |
$315.40 |
| Rate for Payer: Cash Price |
$199.20
|
| Rate for Payer: Cigna Commercial |
$282.20
|
| Rate for Payer: First Health Commercial |
$298.80
|
| Rate for Payer: First Health Workers Compensation |
$128.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$298.80
|
| Rate for Payer: GEHA Commercial |
$232.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$298.80
|
| Rate for Payer: Multiplan All |
$302.12
|
| Rate for Payer: OMNI Networks Commercial |
$232.40
|
| Rate for Payer: One Health Plan PPO/POS |
$298.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$315.40
|
| Rate for Payer: Three Rivers Provider Network All |
$249.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$308.76
|
| Rate for Payer: Zelis Auto |
$132.80
|
| Rate for Payer: Zelis Worker's Compensation |
$90.64
|
|
|
AMOX K CLAV 400-57MG/5ML SUSP
|
Facility
|
OP
|
$332.00
|
|
|
Service Code
|
NDC 00029609239
|
| Hospital Charge Code |
3300049
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$83.00 |
| Max. Negotiated Rate |
$315.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$199.20
|
| Rate for Payer: Cash Price |
$199.20
|
| Rate for Payer: Cigna Commercial |
$282.20
|
| Rate for Payer: First Health Commercial |
$298.80
|
| Rate for Payer: First Health Workers Compensation |
$128.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$298.80
|
| Rate for Payer: GEHA Commercial |
$265.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$298.80
|
| Rate for Payer: Humana ChoiceCare |
$86.32
|
| Rate for Payer: Multiplan All |
$302.12
|
| Rate for Payer: New Mexico Health Connections Medicare |
$199.20
|
| Rate for Payer: OMNI Networks Commercial |
$232.40
|
| Rate for Payer: One Health Plan PPO/POS |
$298.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$315.40
|
| Rate for Payer: Three Rivers Provider Network All |
$249.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$292.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$83.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$308.76
|
| Rate for Payer: Zelis Auto |
$132.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$166.00
|
| Rate for Payer: Zelis Worker's Compensation |
$90.64
|
|
|
AMOX K CLAV 600-42.9MG/5ML SUSP
|
Facility
|
OP
|
$187.00
|
|
|
Service Code
|
NDC 00093867578
|
| Hospital Charge Code |
3300050
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.75 |
| Max. Negotiated Rate |
$177.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$112.20
|
| Rate for Payer: Cash Price |
$112.20
|
| Rate for Payer: Cigna Commercial |
$158.95
|
| Rate for Payer: First Health Commercial |
$168.30
|
| Rate for Payer: First Health Workers Compensation |
$72.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$168.30
|
| Rate for Payer: GEHA Commercial |
$149.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$168.30
|
| Rate for Payer: Humana ChoiceCare |
$48.62
|
| Rate for Payer: Multiplan All |
$170.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$112.20
|
| Rate for Payer: OMNI Networks Commercial |
$130.90
|
| Rate for Payer: One Health Plan PPO/POS |
$168.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$177.65
|
| Rate for Payer: Three Rivers Provider Network All |
$140.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$164.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$46.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$173.91
|
| Rate for Payer: Zelis Auto |
$74.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$93.50
|
| Rate for Payer: Zelis Worker's Compensation |
$51.05
|
|
|
AMOX K CLAV 600-42.9MG/5ML SUSP
|
Facility
|
IP
|
$187.00
|
|
|
Service Code
|
NDC 00093867578
|
| Hospital Charge Code |
3300050
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.05 |
| Max. Negotiated Rate |
$177.65 |
| Rate for Payer: Cash Price |
$112.20
|
| Rate for Payer: Cigna Commercial |
$158.95
|
| Rate for Payer: First Health Commercial |
$168.30
|
| Rate for Payer: First Health Workers Compensation |
$72.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$168.30
|
| Rate for Payer: GEHA Commercial |
$130.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$168.30
|
| Rate for Payer: Multiplan All |
$170.17
|
| Rate for Payer: OMNI Networks Commercial |
$130.90
|
| Rate for Payer: One Health Plan PPO/POS |
$168.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$177.65
|
| Rate for Payer: Three Rivers Provider Network All |
$140.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$173.91
|
| Rate for Payer: Zelis Auto |
$74.80
|
| Rate for Payer: Zelis Worker's Compensation |
$51.05
|
|
|
AMP F/TH 1/2 JT/PHALANX W/NEURECT W/DIR
|
Facility
|
OP
|
$8,596.00
|
|
| Hospital Charge Code |
8126951
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,149.00 |
| Max. Negotiated Rate |
$8,166.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,157.60
|
| Rate for Payer: Cash Price |
$5,157.60
|
| Rate for Payer: Cigna Commercial |
$7,306.60
|
| Rate for Payer: First Health Commercial |
$7,736.40
|
| Rate for Payer: First Health Workers Compensation |
$3,318.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,736.40
|
| Rate for Payer: GEHA Commercial |
$6,876.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,736.40
|
| Rate for Payer: Humana ChoiceCare |
$2,234.96
|
| Rate for Payer: Multiplan All |
$7,822.36
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,157.60
|
| Rate for Payer: OMNI Networks Commercial |
$6,017.20
|
| Rate for Payer: One Health Plan PPO/POS |
$7,736.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,166.20
|
| Rate for Payer: Three Rivers Provider Network All |
$6,447.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7,564.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,149.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,994.28
|
| Rate for Payer: Zelis Auto |
$3,438.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,298.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2,346.71
|
|
|
AMP F/TH 1/2 JT/PHALANX W/NEURECT W/DIR
|
Facility
|
IP
|
$8,596.00
|
|
| Hospital Charge Code |
8126951
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,346.71 |
| Max. Negotiated Rate |
$8,166.20 |
| Rate for Payer: Cash Price |
$5,157.60
|
| Rate for Payer: Cigna Commercial |
$7,306.60
|
| Rate for Payer: First Health Commercial |
$7,736.40
|
| Rate for Payer: First Health Workers Compensation |
$3,318.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,736.40
|
| Rate for Payer: GEHA Commercial |
$6,017.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,736.40
|
| Rate for Payer: Multiplan All |
$7,822.36
|
| Rate for Payer: OMNI Networks Commercial |
$6,017.20
|
| Rate for Payer: One Health Plan PPO/POS |
$7,736.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,166.20
|
| Rate for Payer: Three Rivers Provider Network All |
$6,447.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,994.28
|
| Rate for Payer: Zelis Auto |
$3,438.40
|
| Rate for Payer: Zelis Worker's Compensation |
$2,346.71
|
|
|
AMPHOTERICIN B 50MG
|
Facility
|
IP
|
$302.00
|
|
|
Service Code
|
CPT J0285
|
| Hospital Charge Code |
3302803
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$82.45 |
| Max. Negotiated Rate |
$286.90 |
| Rate for Payer: Cash Price |
$181.20
|
| Rate for Payer: Cigna Commercial |
$256.70
|
| Rate for Payer: First Health Commercial |
$271.80
|
| Rate for Payer: First Health Workers Compensation |
$116.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$271.80
|
| Rate for Payer: GEHA Commercial |
$211.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$271.80
|
| Rate for Payer: Multiplan All |
$274.82
|
| Rate for Payer: OMNI Networks Commercial |
$211.40
|
| Rate for Payer: One Health Plan PPO/POS |
$271.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$286.90
|
| Rate for Payer: Three Rivers Provider Network All |
$226.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$280.86
|
| Rate for Payer: Zelis Auto |
$120.80
|
| Rate for Payer: Zelis Worker's Compensation |
$82.45
|
|
|
AMPHOTERICIN B 50MG
|
Facility
|
OP
|
$302.00
|
|
|
Service Code
|
CPT J0285
|
| Hospital Charge Code |
3302803
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.75 |
| Max. Negotiated Rate |
$286.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$181.20
|
| Rate for Payer: Cash Price |
$181.20
|
| Rate for Payer: Cash Price |
$181.20
|
| Rate for Payer: Cigna Commercial |
$256.70
|
| Rate for Payer: First Health Commercial |
$271.80
|
| Rate for Payer: First Health Workers Compensation |
$116.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$271.80
|
| Rate for Payer: GEHA Commercial |
$47.75
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$271.80
|
| Rate for Payer: Humana ChoiceCare |
$78.52
|
| Rate for Payer: Multiplan All |
$274.82
|
| Rate for Payer: New Mexico Health Connections Medicare |
$181.20
|
| Rate for Payer: OMNI Networks Commercial |
$211.40
|
| Rate for Payer: One Health Plan PPO/POS |
$271.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$286.90
|
| Rate for Payer: Three Rivers Provider Network All |
$226.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$265.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$75.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$280.86
|
| Rate for Payer: Zelis Auto |
$120.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$151.00
|
| Rate for Payer: Zelis Worker's Compensation |
$82.45
|
|
